A multidisciplinary vulva clinic: the role of genito-urinary medicine.

OBJECTIVES: To characterise the new patient referrals to a combined vulva clinic and to assess the role of genitourinary services within the clinic. METHODS: A case note review of all new patients attending a monthly, multidisciplinary vulva clinic over a 12-month period. RESULTS: The mean age of the 135 women was 43 years (range 18-86 years). The majority of patients, 64 (47%), were referred by their general practitioner (GP). Using nurse and physician triage 85 (63%) patients were seen by a dermatologist, 55 (41%) by a genitourinary medicine physician, 38 (28%) by a gynaecologist and six (4%) by a psychosexual physician. Fifty-one (38%) women required a consultation by at least two specialties. Itch was the most frequent presenting symptom (70%) and 59 (44%) women had experienced symptoms for between 6 months and 2 years. A previous STD screen had been performed in only 57 (42%), which was negative in 45 (79%). The most frequent initial clinical diagnoses were lichen sclerosus (35, 26%), vaginal candidiasis (21, 16%), vulvodynia (16, 12%), lichen simplex chronicus (13, 10%) and Bowenoid papulosis (13, 10%). Thirty-eight (28%) women had microbiological investigations revealing 13/135 (10%) had vaginal candidiasis and two (2%) bacterial vaginosis, all symptomatic. A biopsy was performed in 32 (24%) confirming the initial diagnosis in 20 (63%) cases. Treatment was initiated in 101 (75%) women: 62 (46%) were prescribed steroid cream, 46 (34%) emollient cream and 22 (16%) treatment for candida infection. Fifty-three (39%) women received more than one treatment. 94 (70%) patients were followed-up in the vulval clinic, five (4%) in the genitourinary clinic and 12 (9%) by their GP. CONCLUSIONS: Despite having genitourinary symptoms less than half the patients had been tested for infection prior to attending the clinic. More than a third of the patients, 46 (34%), were diagnosed with a genitourinary infection. There is a significant role for genitourinary services in the diagnosis, management and ongoing care of patients in a vulva clinic.

A maternal death caused by AIDS. Case report.

PIP: Physicians at a district general hospital in London, England admitted a 26 year old pregnant political refugee from Uganda complaining of shortness of breath, fever, and a productive cough for 1 week. She was at 10 weeks gestation and had not yet sought prenatal care. 6 years earlier she had a child and her pregnancy and delivery were normal. They diagnosed an interstitial pneumonia based on an X ray, arterial gases, and quick breathing and administered intravenous (IV) ampicillin and erythromycin for 3 days. Her condition deteriorated nevertheless, so they had her blood tested for HIV. She tested positive and suspected pneumocystosis (later confirmed) and began treatment with IV Septrin and hydrocortisone. She worsened, and by the 10th day of this treatment she was receiving 60% oxygen. They changed her treatment to IV pentamidine and oral rifampicin and isoniazid. By this time, her white blood cell count was 28.7x109/1 and hemoglobin concentration 8.2g/dl. Her condition would not allow her to undergo general anesthesia so an abortion requested by the patient was not performed. Additional treatment included continuous infusion of eflornithine, but she died despite it. This case poses 2 questions. Could she have lived if there had not been a delay in HIV diagnosis? Research shows that CD4 lymphocytes cell counts fall considerably during pregnancy in HIV positive women. So some advocate prophylaxis earlier in these women than other immunocompromised patients. Was it indeed her pregnancy that contributed to the severity of her illness and its inability to respond to treatment? Some researchers find pregnancy accelerates the progress of HIV infection, but researchers do not yet know if it also accelerates the progress of opportunistic infections. If so, terminating pregnancy may be considered.^ieng

HIV infection and pregnancy.

This article discusses some aspects of the epidemiology and neonatal transmission of the acquired immunodeficiency syndrome (AIDS). Various screening approaches are reviewed, and the interaction between pregnancy and AIDS is considered. Management of the pregnancy and subsequent advice and follow-up are described.

Plasma oestrogens in a pregnancy associated with chronic haemodialysis.

Pregnancy in a patient undergoing regular haemodialysis at home is described. The pregnancy was complicated by antepartum haemorrhage due to a Type I placenta praevia, and premature labour occurred at 32 weeks, resulting in spontaneous vaginal delivery of a live infant which survived. Plasma progesterone oestrone, unconjugated oestradiol and oestriol levels were normal during the last two weeks of pregnancy, but failed to show a characteristic fall in the puerperium. The conjugated oestriol fraction was 20 to 30 times the normal mean level and did not fall after delivery. These findings are discussed.